New vaccines are not the only answer to malaria

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In response to recent statements by the UK Chancellor of the Exchequer, Gordon Brown, Bob Snow and Nick White argue that researchers must not become fixated on high-tech approaches to controlling malaria when effective low-cost approaches already exist.

Dear Mr Brown,

We write regarding your recent announcement that the British government is ready to enter into an agreement to purchase a large quantity of malaria vaccine in advance to ensure a secure market. We think you can do more for less — now.

The results of the trial published in the medical journal The Lancet on 16 October were exciting indications that, for the first time, a clinically relevant protection against malaria (vaccine protective efficacy: 30 per cent) could be provided by a vaccine in young African children. This was associated with vigorous and eye-catching publicity, notably the banner headline in The Times the preceding day claiming "New malaria vaccine will save millions of children".

We have waited a long time for evidence that an effective vaccine against falciparum malaria might be possible. But we have had false dawns with malaria vaccines before — and it would be prudent to be cautious.

Under normal circumstances, this report would herald a concerted effort to confirm or refute the findings in different populations in different parts of Africa with studies large enough to measure the impact on mortality from malaria; one study is certainly not enough to be sure of anything. But instead, you announced a week ago that the British taxpayers would pre-buy 300 million doses of vaccine for sub-Saharan Africa, costing probably £3 billion (US$5.75 billion).

The UK government is to be applauded for recognising malaria as a major cause of poverty, suffering, and death in the developing world. Malaria weakens and debilitates developing world societies perpetuating a vicious cycle of illness and grinding poverty. Consistent negative economic growth in Africa over the past half-century has been ascribed to malaria. Childhood deaths from malaria are on the rise in sub-Saharan Africa.

The UK government has shown its concern and commitment to reverse this appalling trend while some other rich countries have turned away, seeing this as an interminable and insoluble problem. But it is not; malaria really can and should be conquered — and we now have the necessary tools to do the job.

We are seriously concerned, therefore, that while millions of people suffer every year, you are proposing to allocate precious funds to a future uncertainty. This good intention is misguided. We fear you have been advised poorly.

We have interventions now that are more effective and much less expensive than the weak vaccine reported in The Lancet. In particular, just two simple approaches could halve the numbers of malaria attacks in young African children and save more than one in five of all childhood deaths.

A mosquito net treated with a long-lasting insecticide costs less than US$4. While we already have highly effective and well-tolerated antimalarial drugs (artemisinin-based combination treatments; ACTs) to replace those drugs such as chloroquine that have fallen to resistance. These cost less than US$1 per child treated. Less than US$20 would guarantee a poor African child access to life-saving interventions. The cost of a malaria vaccine will be in excess of US$60 per full immunisation.

The sad truth is that, despite having now developed these effective tools (with substantial support from donors such as the UK government), the international community has failed in its promise to make them accessible to people most in need. Furthermore, partnerships such as the World Health Organization, Roll Back Malaria, and the Global Fund against HIV, TB, and malaria — also supported generously by the UK government — have missed opportunities to go to scale with comparatively cheap, life-saving interventions.

Weak strategic leadership, donor-driven agendas making poor people pay for bednets, inadequate planning for drug needs and policies, and lack of sufficient funds have all resulted in less than five per cent of children sleeping under an insecticide treated bednet, and a handful of African countries struggling to implement new effective drug policies.

Communities in Africa under the constant threat of malaria and maintained in a constant state of poverty cannot afford to spend US$20 per child to save them from malaria; rural households have to make difficult choices of putting food on the table or sending their children to school.

Nor can their governments provide for them adequately, and depend largely or entirely on donor support. No-one likes to be dependent on aid. But we will not roll back malaria without substantial donor support. If we could persuade the developed world to match commitments such as those made generously by you, and these were spent wisely on insecticide treated bednets and ACTs, then we would have made substantial inroads into malaria by the time any malaria vaccine became generally available.

Why, then, has the UK government decided to invest in an intervention that is more expensive and less effective than bednets and effective drugs? One argument might be that the bill does not have to be paid today. And when it does, it will probably be paid to a British multinational pharmaceutical company.

Another is that vaccination is a simple tool that has been highly effective in combating some of the greatest infectious disease scourges — including smallpox, diphtheria, and polio. We could add to this list pneumococcal disease (the main cause of pneumonia in the world), tetanus, and measles. But in the developing world, these diseases still kill over two million children every year.

We have truly effective measles and tetanus vaccines (they are much more effective than the current malaria vaccine), and we have had them for decades. But these vaccines still do not reach all those who need them. Together measles and tetanus kill over a million children each year (World Health Reports 2003, 2004). Similarly, although we have a pneumococcal vaccine, it does not reach anyone because it is so expensive that no developing country government can afford it.

The prospect of a new vaccine against a killing disease has a seductive 'high-tech', 'feel-good' allure that is appealing to donors who seek neat solutions in modern technology. There is also the argument that vaccines could reduce the incidence of the disease, thereby reducing the need for other interventions.

Yes, prevention is better than cure. But this works both ways. If we provide insecticide-treated bednets and make effective drugs available, this will also reduce the incidence of malaria, and we will achieve better effects than with a weakly effective vaccine — and importantly we will spend less money.

The burden of malaria is increasing alarmingly; we could and we should ACT now. We are not arguing against support of malaria vaccine development, only for a sensible direction of your genuine humanitarian initiative with the most efficient and effective allocation of precious resources. Investment in developing a malaria vaccine is critical.

The trial in Mozambique has shown us that despite all our earlier reservations we may well have a vaccine against malaria for African children. It is not a question of whether we spend money on vaccine research and development or on expanding coverage of bednets and effective drugs — we must spend money on both, but spend it wisely to give the greatest benefit.

Mr Brown, please do the right thing. The disempowered, poverty-stricken millions who cannot afford even basic, but well-tested and effective, bednets and drugs to protect them and their children against malaria need you. They need leadership and commitment to drive a concerted humanitarian global effort to tackle this soluble but lethal problem.

We need to raise sufficient funds from the rich world to support scale up and deployment of what we know works best, and we must do it now.

Bob Snow is professor of tropical public health at the Kenyan Medical Research Institute in Nairobi and the University of Oxford. Nick White is professor of tropical medicine at Mahidol University, Bangkok, Thailand, and the University of Oxford.